Referral Type (required)
    LE CARE ReferralCommunity Referral

    LE Incident # (if applicable) (required)

    CARE Eligibility Check

    If Yes to either question, individual is NOT eligible for CARE.

    Are you currently a participant in an Adult Drug Court program? (required)
    Are you currently on probation or parole? (required)

    Referring Person

    Date (required)

    Agency/Dept. (required)

    Referred by (required)

    Email (required)

    Client Information

    First Name (required)
    Middle Name
    Last Name
    Date of Birth (required)
    Social Security # XXX-XX- (required)
    Race/Ethnicity (required)
    Gender (required)
    Phone Number (required)
    Voicemail (required) YesNo
    Physical address
    If no address- where can CARE staff locate you?

    The information below is helpful for locating a client when a warm handoff with the case manager is not possible.

    Where did you sleep last night?
    Describe physical appearance or identifying clothing/items/etc.
    Do you have a job? YesNo
    If so, where?

    Additional information (including recent charges):